RH Vouchers and Health Systems

RH Vouchers and Health SystemsBen Bellows, PhDThe Role of Vouchers in Serving Disadvantaged Populations and Improving Quality of Care

November 6th 2014World Bank, Washington, DC

Overview• Necessary conditions for successful RH voucher programs?

• Design characteristics of voucher programs?

• What is the coverage for RH voucher programs?

• How much would it cost to scale up RH voucher programs?

• How can vouchers fit into national objectives and international health goals?

Consider pre-conditions for scaled voucher programs

POPULATION

PROVIDERS

HEALTH SYSTEM &

GOVERNANCE

Population characteristics

• Gap in high quality RH service consumption

• Inequity in distribution of RH services & ability to pay

• Ability to identify target population• Beneficiary’s agency on FP/RH issues

(e.g. future-oriented, ability to make decisions, male support)

Health care provider characteristics • Facilities must meet standards to be contracted

– Tanzania (equipment to public facilities)– Cambodia (MOH QoC standards: pass, no pass)– Uganda (A, B, C)

• Routine quality improvement: QoC decreases are of concern• Providers located in areas accessible to target population

(transportation issues & marginal quality at remote facilities)• Composition of providers

– public/private – dual practice

• Capacity to treat and efficiency with increased volume of patients

Use of voucher reimbursements in Kenya 2009-2011

Construction Maternity wing; others Renovation and Repairs Maternity wing; other; sanitary (water, toilets etc) Human resources employment of doctors, nurses, support staff, salaries & wages, staff incentives, training Medical procurement Beds, nets, medical equipment, drugs, medical supplies Non-medical procurement Vehicle, land, furniture, water or power equipment, appliances, non-medical supplies Other recurrent costs Patient nutrition/meals, incentives to mothers, repair of medical equipment, service hire

Facility efficiency in provision of delivery services: Kenya

Kyam

beke H

C

Mbit

ini H

C

Mia

mbane H

C

Yatt

a H

C

Lari

HC

Ngew

a H

C

Nyanza P

GH

Kit

ui D

H

Kia

mbu D

H

Tig

oni SD

H

Kauw

i SD

H

Muti

to S

DH

Chula

imbo D

H

Kis

um

u E

ast

DH

Lim

uru

NH

St

Tere

sa N

H

St

Monic

a H

ospit

al

Nig

hti

ngale

Hospit

al

Port

Flo

rence H

ospit

al

St.

Elizabeth

Chig

a D

is-

pensary

Health Center Hospitals Hospitals Dispensary

Public Facilities Private Facilities

0%

20%

40%

60%

80%

100%

Facilities

Effi

cie

ncy S

core

s

Government and health system characteristics• Voucher management agency

– autonomy– capacity to quickly & consistently disburse on time– measure quality– “trouble shoot” or innovate – Avoid over-centralized planning and adding burdens

to existing agency without sufficient support

• Vouchers ought not to compete with existing programs with similar goals (e.g. Cambodia and health equity funds)

Coverage by RH voucher programs

Country (DHS & program years)

Total births

% facility-based births (DHS)

Births at poorest 40% HH

% facility births for poorest 40% (DHS)

Yearly vouchers issued

Yearly voucher deliveries

Voucher deliveries among all deliveries (yearly)

Voucher deliveries among bottom 40%

Cambodia (2010, 2013) 367,000 53.8% 146,800 39.2% 9,248 5,814 1.6% 4.0%Bangladesh (2011, 2013)

3,401,000 29.0%

1,360,400 13.7%

156,937

129,616 3.8% 9.5%

Kenya (2009, 2013)

1,596,733 43.0% 638,693 24.2% 53,404 45,354 2.8% 7.1%

Tanzania (2010, 2013)*

1,813,385 50.0% 725,354 34.7% 45,751 15,160 0.8% 2.1%

Uganda (2011)

1,502,000 57.4% 600,800 45.6% 58,397 31,012 2.1% 5.2%

Scaling beyond pilot programs for effective social protection: Kenya

• 2011 MOH budget US$465 million (41 billion KES)

2015Deliveries among 40% poorest 410,443

Service reimbursement $46,450,233 Program management $6,406,929

Total cost $52,857,161 Cost per maternal voucher $128.78

International health goals: UHC1. Access: expand population covered2. Scope: improve quality /quantity of

health services offered3. Financial protection: improve size of

subsidies (or regulation of informal charges)

Conclusions

• Vouchers can work, but consider conditions and have an appropriate design

• Vouchers can be a responsive, scalable strategy to accelerate progress on global health priorities

• Incomplete evidence:– Do vouchers prime users and providers for a better

understanding of insurance concepts?– How to standardize and validate equity measurement in

voucher program operations (e.g. DHS quintiles)?– What “nudge” strategies can convert voucher holders to

service users (e.g. lotteries, expiry dates)?

Thank you